Graduate School PROOF OF IMMUNIZATION COMPLIANCE

Louisiana R.S. 17:170/Schools of Higher Learning Name : Date of Birth: Sep 02 1983

Ali
(Last)

Md Hazrat
(First)

(M.I.)

Student ID#: 110134751

Email Address:

Instructions: Immunization requirement is applicable ONLY to students born on or after January 1, 1957. Students born on or after January 1, 1957 must complete Section A and Section C. Section A MUST be completed by a Physician or Health Care Provider. No attachments or photocopies accepted. If you have not been immunized for all required diseases, you may request an exemption by completing Section B. Section A : Requirements
(Please Omit Gray Areas)
Date of 1st Dose Date of 2nd or Most Recent Dose Date of Disease/Results or Serologic Test/Results

Measles\Mumps\Rubella MMR (Two doses)

OR
Measles (Two doses) Mumps (At least one dose) Rubella (At least one dose) Tetanus-Diphtheria (Booster within the past 10 Years) Meningitis Menanctra (One dose) - Licensed Jan. 2005, available in U.S. ONLY

OR
Menomune (One dose within the past 3 years)

Signature of Physician or Health Care Provider

Date

Address

Telephone

Section B : Immunization Exemption Request

Request for Immunization Exemption: I have chosen not to be vaccinated for one or more of the above-listed
diseases and I am aware of the disease risks. I am requesting an exemption from immunization for the disease(s) in which an inoculation is not listed. I understand that if I claim exemption for personal or medical reasons, I may be excluded from campus and from classes in the event of an outbreak of measles, mumps, rubella, tetanus-diphtheria, or meningitis until the outbreak is over or until I submit proof of immunization.

Reason for Immunization Exemption Request (please check one):

Medical (physicians statement below) Reason\Physicians Statement: Students Signature Date Personal (state reason in space below) Shortage (unable to locate vaccine)

Section C : Signatures (Must be completed by ALL students)

I have reviewed information regarding vaccine-preventable diseases and related vaccinations contained on the website of the Center for Disease Control and Prevention (CDC): http://www.cdc.gov/nip/publications/VIS/default.htm. Students Signature Date

Please return the completed form to: UL Lafayette; Graduate School; PO Box 44610; Lafayette, LA 705044610
Revised: 02/08